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PATIENT HISTORY
Name: Date of Birth:
PAST MEDICAL HISTORY:
Have you ever been diagnosed with any of the following?
PATIENT HISTORY FAMILY HISTORY High Blood Pressure ____ Yes ____No ____ Yes ____No Diabetes Mellitus (sugar) ____ Yes ____No ____ Yes ____No Angina Pectoris (Chest Pain) ____ Yes ____No ____ Yes ____No Heart Attack ____ Yes ____No ____ Yes ____No Irregular Heart Beats ____ Yes ____No ____ Yes ____No Hypertension ____ Yes ____No ____ Yes ____No High Cholesterol ____ Yes ____No ____ Yes ____No Blood Clots ____ Yes ____No ____ Yes ____No Anemia (low blood count) ____ Yes ____No ____ Yes ____No Stroke ____ Yes ____No ____ Yes ____No Emphysema / COPD ____ Yes ____No ____ Yes ____No Asthma ____ Yes ____No ____ Yes ____No Other Breathing Problems: ___________ ____ Yes ____No ____ Yes ____No Hepatitis ____ Yes ____No ____ Yes ____No Hypothyroidism (Low Thyroid) ____ Yes ____No ____ Yes ____No Arthritis ____ Yes ____No ____ Yes ____No Kidney Stones ____ Yes ____No ____ Yes ____No Rheumatic Fever ____ Yes ____No ____ Yes ____No Ulcers (Bleeding) ____ Yes ____No ____ Yes ____No Cataract ____ Yes ____No ____ Yes ____No Glaucoma ____ Yes ____No ____ Yes ____No TB / Positive Skin Test ____ Yes ____No ____ Yes ____No Mental Health Treatment ____ Yes ____No ____ Yes ____No
Please Specify: ___________________
Other, please specify: ____________________________________________________________________________________________________
____________________________________________________________________________________
Cancer: ____ Yes ____No ____ Yes ____No What kind:_____________________________________ When?_______________________ What kind:_____________________________________ When?_______________________ What kind:_____________________________________ When? ______________________
Medical Record Number:
Revised 7/31/19 1 of 4
PATIENT HISTORYOBSTETRICS AND GYNECOLOGY HISTORY:
Last Menstrual Period: _________________ Are you sexually active? _____Yes _____No Please specify, if any, irregularities about your period: ____________________________________________________________________________________ Child Birth: __________________________________________________________________________ Abortions, miscarriages, stillbirths, C-sections: ______________________________________________
WHAT OTHER PROVIDERS DO YOU SEE? or HAVE YOU SEEN IN THE PAST?
Name: ____________________________ Name: _____________________________________
Address:___________________________ Address: ____________________________________
Phone Number: _____________________ Phone Number: ______________________________
Specialty: __________________________ Specialty: ___________________________________
Name: ____________________________ Name: _____________________________________
Address:___________________________ Address: ____________________________________
Phone Number: _____________________ Phone Number: ______________________________
Specialty: __________________________ Specialty: ___________________________________
PAST SURGICAL HISTORY:
Have you ever had any of the following operations? If so, when?
Appendectomy (Appendix) _____Yes _____No __________ Date / Year Tonsillectomy (Tonsil Removal) _____Yes _____No __________ Date / Year Cholecystectomy (Gallbladder) _____Yes _____No __________ Date / Year Hysterectomy (Uterus) _____Yes _____No __________ Date / Year Mastectomy (Breast Single or Bilateral) _____Yes _____No __________ Date / Year Bypass Surgery (Heart) _____Yes _____No __________ Date / Year Cataract Laser _____Yes _____No __________ Date / Year Hemorrhoidectomy (Hemorrhoids) _____Yes _____No __________ Date / Year Colectomy (Colon Removal) _____Yes _____No __________ Date / Year Hernia Repair _____Yes _____No __________ Date / Year Anesthesia Complications _____Yes _____No __________ Date / Year
Other, please specify: ____________________________________________________________________________________________________
____________________________________________________________________________________
Recent ER Visit/Hospitalization? _____Yes _____No ______ Date Date:_____________ Reason: _________________________________________
Patient Name: ______________________________
Date of Birth: ______________________________
MRN: ______________________________Revised 7/31/19 2 of 4
PATIENT HISTORYPRIOR EXAMS and IMMUNIZATIONS:
DATES DATE OF DOSE (mm/dd/yy)
Exam 1 2 3 Vaccine 1 2 3 4 5
Periodic Health Exam Polio
EKG DTP
Cholesterol Test DT or Td
Chest X-ray MMR
Pap Smear HIB Meningitis
Mammogram (Breast Exam)
Mumps
Prostate Exam Rubella
Colonoscopy Measles
Sigmoidoscopy Chicken Pox
Stool Test (FOBT) Tetanus
Bone Mineral Density Test
HPV
Diabetic Eye Exam Pneumovax
Dental Exam Hepatitis
Glaucoma Screening Zostavax
Do you need any immunizations today? _____Yes _____No
CURRENT MEDICATIONS:
Medicine: _____________________ Dose: ____________ (mg) How often____________________
Medicine: _____________________ Dose: ____________ (mg) How often____________________
Medicine: _____________________ Dose: ____________ (mg) How often____________________
Medicine: _____________________ Dose: ____________ (mg) How often____________________
Medicine: _____________________ Dose: ____________ (mg) How often____________________
Medicine: _____________________ Dose: ____________ (mg) How often____________________
*Add additional medications to the back of this form
Patient Name: ______________________________
Date of Birth: ______________________________
MRN: ______________________________
Revised 7/31/19 3 of 4Revised 7/31/19 3 of 4
PATIENT HISTORYALLERGIES:
Seasonal _____ Yes _____No Animals _____ Yes _____No
Medication _____ Yes _____No
Medicine: _______________________________ Type of Reaction: _____________________________
Medicine: _______________________________ Type of Reaction: _____________________________
Medicine: _______________________________ Type of Reaction: _____________________________
SOCIAL HISTORY:
Do you smoke? _____ Yes _____No How much/How long? ____________________
If stopped, how long ago? __________________________________________________
Do you drink Alcohol? _____ Yes _____No How much? ____________________________
If stopped, how long ago? __________________________________________________
Substance Abuse? _____ Yes _____No How much? ____________________________
If stopped, how long ago? __________________________________________________
Do you exercise regularly? _____ Yes _____No How much? _____________________________
Are you on any special diet? _____ Yes _____No What diet? _____________________________
Do you need any special assistance?
_____ Yes _____No What kind? _____________________________
Have you traveled outside of the country recently?
_____ Yes _____No What kind? _____________________________
Do you live in more than one location throughout the year?
_____ Yes _____No
***Please remember to provide us with any alternate contact and provider information
Do you have Advanced Directives / Living Will _____Yes _____No ***Please bring a copy for your provider
_________________ _____________________________________________________ DATE PATIENT SIGNATURE
Patient Name: ______________________________
Date of Birth: ______________________________
MRN: ______________________________Revised 7/31/19 4 of 4
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